The undersigned organizations represent cancer patients,
health care professionals, and clinical researchers.
We appreciate the opportunity to comment on the work of
the National Association of Insurance Commissioners (NAIC)
Regulatory Framework (B) Task Force to update the managed
care network adequacy act. We commend the Task Force
for provisions of the Health Benefit Plan Network Access
and Adequacy Model Act that would offer patients some
protections in obtaining out-of-network care. The
out-of-network access provisions of the model act are of
great importance to cancer patients, who often need timely
specialty care that is not available in network. We
recommend some modifications to the draft that would
improve patients’ ability to obtain necessary care
accompanied by appropriate financial protections.

Process for Obtaining Care Out-of-Network (Section
5(C))

As currently drafted, the model act would require a health
carrier to have a “process to assure that a covered person
obtains a covered benefit at in-network level of benefits
from a non-participating provider” if the covered person
is diagnosed with a condition or disease that requires
specialized health care services or medical services and
the health carrier does not have a network provider of the
required specialty with the professional training and
expertise to treat or provide health care services for the
condition or disease or cannot provide access to an
appropriate in-network provider without unreasonable
delay.

We propose that additional language be added to the model
act to define the process that the insured individual must
follow and the information that the individual must
provide to obtain out-of-network care. The model act
states that out-of-network care might be necessary if the
carrier does not have a network provider of the required
specialty with the professional training and expertise to
provide health care services for the condition or disease.

We recommend that the model act be amended and that
accompanying regulatory language be developed to ensure
that patients receive care provided according to clinical
practice guidelines or current best practice, and that
such care be available out-of-network if there is no
provider who can supply care that meets current best
practice. For example, care by an in-network
oncologist may not be adequate if that provider has little
or no experience in treating the rare cancer of a
patient. This problem is a serious concern for
children with cancer, where engagement of pediatric
specialists and pediatric sub-specialists is critical to
be sure that children receive quality treatment and
survivorship care. In addition, a general surgeon
may be part of a carrier’s network, but that surgeon might
not have the necessary expertise or familiarity with
current practice standards to operate on a patient with
advanced ovarian cancer. In these examples, the
providers might be considered to have professional
training to care for these patients, but their experience
might not in fact be adequate to ensure quality care for
patients with these rare or complex conditions.

We recommend that the language of Section 5(c)(2)(b)(I) be
amended to read, “Does not have a network provider of the
required specialty with the professional training and
expertise or knowledge of relevant treatment guidelines or
standards of care to treat or provide health care services
for the condition or disease.” Regulatory
language implementing and explaining the model act should
provide details about out-of-network providers who might
be available to patients with rare, complex, or
difficult-to-treat cancers. We urge that states
adopting and implementing the model act consider
identifying providers at cancer centers, including but not
limited to National Cancer Institute-designated cancer
centers, as out-of-network providers whose services would
be available to patients in the complex clinical
situations described above.

We also recommend a more specific definition of the
process for obtaining out-of-network care. The model
act should be revised to set concrete standards for this
process, so that a covered person with an urgent or acute
medical condition could be assured access to an
out-of-network provider within 24 hours. The access
plan filed by the carrier should provide specific
information about the exceptions process for obtaining
out-of-network care.

We also recommend that a determination that a covered
person should be provided access to care out-of-network
should be applicable for the full course of treatment or
remainder of the plan year, whichever ends first.
Cancer patients should not be required to undergo the
exceptions process on multiple occasions during the course
of treatment.

We are pleased that the model act includes a provision to
discourage discriminatory benefit design. The model
act states that the criteria that carriers must use to
select participating providers would not permit carriers
to exclude providers “because they treat or specialize in
treating populations presenting a risk of higher than
average claims, losses, or health care services
utilization.” The inclusion of this protection
against discriminatory benefit design is important as a
protection for cancer patients who may be above average
health care utilizers during their treatment.
Medical groups that treat large numbers of cancer patients
and especially those who treat complex and rare cancers
are readily identified, and their exclusion would
constitute a discriminatory benefit design that would at
the very least limit the plan choices of cancer
patients.

The requirements in the model act related to notification
of covered individuals regarding the termination of a
network provider and the continuation of care after
termination are inadequate to meet the needs of covered
individuals with cancer. We recommend that Section
6(L)(1)(b) be revised to require notification of
termination of “all covered persons who are patients seen
in the last 5 years by the provider whose contract is
terminating.” Cancer patients may require
significant follow-up monitoring and care after completion
of active treatment, and the patient’s cancer care
provider is often the provider who coordinates that
care. Those patients might not meet the definition
of seeing the terminated provider “on a regular basis” as
required by the model act language, but notice of
termination of provider is important for those patients so
that they may make arrangements for management of their
follow-up care.

The provision related to continuation of care in the case
of termination of a provider is also inadequate to meet
the acute health care needs of cancer patients. The
model act provides for “affected covered persons with
acute or chronic medical conditions in active treatment to
continue such treatment until it is completed or for up to
ninety (90) days, whichever is less.” This provision
would force a disruption of care for some cancer patients,
whose course of treatment at the time of provider
termination would exceed 90 days. We recommend that
this provision be amended to read, “Whenever a provider’s
contract is terminated without cause, the health carrier
shall allow affected covered persons with acute or chronic
medical conditions in active treatment to continue such
treatment until is it completed or for up to ninety (90)
days, whichever is greater.”

Provider Directories (Section 8)

The standards of the model act related to online posting
of the carrier’s provider directories will be useful in
informing the consumer regarding network providers.
We support the standards of the model act that require
online posting of the carrier’s provider directories with
search functions that will provide covered individuals
information about hospital affiliation, medical group
affiliations, board certifications, and certain other
data. However, we also recommend that the provider
directory information include data about the affiliation
of the provider with cancer centers, including but not
limited to National Cancer Institute-designated cancer
centers. The monthly updating standard also helps to
ensure that covered individuals have reasonably up-to-date
information.

We also recommend that the posted online information
include data about the carrier’s exceptions process and
how that process is administered. We propose that
the online posting requirements, which should be included
in the access plan filed by the carriers, include
information about the average length of the exceptions
process, the percentage of exceptions that are granted,
and the reasons that exceptions are denied.

We also propose that carriers be required to monitor
consumer complaints about access to out-of-network care
and offer reports regarding these complaints by online
posting.

Disclosure and Notice Requirements (Section 7)

Covered individuals in many plans have suffered
significant financial responsibility associated with care
provided by out-of-network providers when patients receive
care in in-network hospitals. Individuals have
suffered this burden despite making every effort to obtain
care from in-network providers. The model act is not
adequate in addressing this serious consumer
exposure.

The model act includes provisions requiring disclosure and
notification to covered individuals that they might
receive care from an out-of-network provider while
receiving care in an in-network hospital. These
provisions of the model act should be modified to require
that out-of-network care that is provided to a covered
individual in an in-network facility is reimbursed as if
it were in-network care.

The model act as currently written does not permit the
patient to make an informed decision about his or her
care, including efforts to obtain protection from
financial exposure associated with out-of-network
care. Advance notice that an individual might
receive out-of-network care at an in-network hospital is
not sufficient. These patients might be in no
position to decline the out-of-network care and are
unlikely to be able to request and receive in-network care
as a substitute for the out-of-network care that is
provided in the in-network hospital.

The model act should instead be revised to protect a
covered person from balance billing for services rendered
in an in-network facility by an out-of-network health care
professional, unless the covered person authorizes in
writing and in advance of receipt of services that he/she
has chosen to be treated by an out-of-network health care
professional and is aware of the additional costs
applicable as a result of selecting an out-of-network
provider.

Application of Network Adequacy Protections

Network adequacy protections should apply to all health
plan designs that are within the jurisdiction of a state’s
insurance commission.

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We appreciate the opportunity to comment on the network
adequacy model act.